Parents should know that young children experience OCD differently than adolescents and adults. The disorder can manifest as early as 5, but a child may lack the self-awareness to recognize that his thoughts and fears are exaggerated or unrealistic, and he may not be fully aware of why he is compelled to perform a ritual; he just knows that it gives him what our expert calls a “just right feeling,” at least momentarily. Later, what professionals call “magical thinking” emerges: Though he knows it is far-fetched, a child finds himself compelled to scratch his right shoulder if he scratches his left shoulder so mom will be less likely to die in a car accident, for instance. In any case, the response is highly structured and repetitive, making the child appear rigid and rule-bound and interfering with normal. And while all children seek reassurance from adults, children and adolescents with OCD pepper elders with repeated questions about the future.
Experts agree that most OCD obsessions fall in to the following categories: contamination (germs, waste, bodily fluids, chemicals, etc.), symmetry (lack of which could cause bad luck), fear of harm or responsibility for harm (the house will burn down), aggressive (I might hurt the baby) and sexual (What if I become a pedophile?). Since obsessions can be impulses as well as ideas or images, the compulsion in response to a dreaded impulse can be to avoid contact or problematic situations, or isolate oneself. Likewise, the rituals performed can be mental rather than physical, and go unrecognized by parents—and even the child.
Mild cases of OCD are often treated with cognitive behavior therapy alone, or medication alone; research shows them to be equally effective. But as symptoms intensify or impairment reaches the moderate to severe range, the best approach is the combination of CBT and medication.
Psychotherapeutic: OCD is best treated with cognitive behavior therapy, specifically a technique called exposure and response prevention. This technique introduces your child to the objects of his obsession in incremental doses in a controlled environment, in which he can experience his anxiety and distress without resorting to compulsions. Over time, as your child confronts his fears instead of attempting to neutralize them, he will become habituated, the anxiety response will diminish, and the obsession will become “boring.” The professional will work with your child to develop a “fear hierarchy,” and work on exposure from the easiest, least stressful trigger of OCD behavior up to the most dreaded. Much of the work and improvement is done at home, as the whole family is trained by the clinician to work on exposure tasks. Our clinicians caution that traditional talk therapy does not help children with OCD, as talking about the disorder can increase anxiety about obsessions. In fact, talk therapy can make symptoms worse.
Pharmacological: More severe cases of OCD are often treated with a combination of CBT and medication, including SSRIs, or selective seratonin reuptake inhibitors. The medication reduces anxiety and allows the child to be more amenable to doing the exposure therapy. Once she has acquired skills to overcome the anxiety, medication can be decreased or discontinued.
Whether the treatment is behavioral or pharmacological or both, OCD patients will often return to their clinician in the years following their initial treatment for “booster sessions” to freshen up the skills they learned to control their anxiety levels.
No. Though OCD has many causes—genetic, neurobiological, environmental—it is not the result of “unresolved issues” in childhood, or of a traumatic experience. However, even the best intentions of a parent of a child with OCD to help him manage his obsessions and to accommodate compulsions can actually perpetuate and exacerbate the disorder, so parent training and education is a key part of any treatment undertaken by a professional. The clinician will give you “do’s and don’ts” to help your child work to overcome OCD.
Do I have to tell my kid’s school?
If OCD is well managed by treatment, there is no reason the school needs to know. But teachers and school officials can be of great help to a child with OCD. Reading and writing in class may be a minefield for him, if a “bad” word or mistake triggers OCD behavior; a knowledgeable teacher will be able to respond more effectively to his distress or distraction. It may be beneficial to include as many caring adults as possible in your child’s treatment.
How is CBT different than traditional talk therapy?
Cognitive behavioral therapy exposes your child to his obsessions in carefully calibrated doses, to allow him to build up tolerance for the anxiety without resulting to the compulsions he has used to “fix” it. Gradually the obsessions lose their power. Talking about these obsessions and compulsion with a therapist who doesn’t really understand your child’s problem can actually exacerbate them. CBT for OCD is backed up by evidence, and therapists trained in the method are taught exactly how to employ it.
What should I ask a possible therapist?
You should make certain that your child’s therapist is experienced with OCD patients and the therapies used to treat it. Ideally, a professional will have seen hundred of OCD sufferers, and will have training in CBT, specifically exposure therapy. Beware the therapist who says, “Sure, I do a little bit of that.” Other approaches that are superficially similar, such as controlled desensitization, won’t be effective for an OCD patient.
How long will therapy last?
While some cases are handled relatively quickly, others can take quite a while to unravel. And for many people with OCD, managing the symptoms is a lifelong endeavor.
How involved should parents be in treatment?
Very. Most positive change in OCD patients comes between office sessions, as families educated in OCD therapies help their kids own their own treatment. This is not the kind of treatment parents refer to as “drop off and pick up,” in which parents are no more than chauffeur. If parents are not deeply involved in the treatment, it will not be as effective.
Will my child grow out of his obsessions and compulsions?
Compulsions temporarily alleviate the anxiety of OCD. But, like scratching a bug bite, performing them often results in increasingly severe obsessions and more impairing compulsions, a vicious spiral that can only be addressed by smart, focused therapy.